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Human ResourcesEmployee Benefits and ServicesRetiree Benefits &Enrollment GuideWhat’s New in 2021Contact InformationBenefit OptionsHow to Enroll in BenefitsEnrollment FormsOpen Enrollment is from November 1– November 30, 2020
TipsOpen Enrollment Review this guide and visit link.sbcounty.gov/Retiree-Benefits tolearn more about your retiree health plan options Review What’s New for Plan Year 2021 (page 4) Check important dates for open enrollment 2021 (page 4) Prepare for your transition from COBRA to retiree health benefits Prepare for your transition from traditional to Medicare benefits Enroll and make changes by 5:00 p.m. November 30, 2020 Submit any required dependent documentation to Employee Benefitsand Services Division (EBSD) by December 7, 2020Contact EBSD at:EBSD: 909-387-5787EBSD Toll-Free: 888-743-1474EBSD Email: ebsd@hr.sbcounty.gov Attn: Retiree DeskOpen enrollment is November 1 through November 30, 2020https://link.sbcounty.gov/RetireeOEYou are encouraged to keep this guide throughout the year.Castle Rock Trail, San Bernardino National Forest, Big Bear Lake, California
2021 San Bernardino County Retiree Benefits GuideINTRODUC TIONTABLE OF CONTENTSPAGEWelcome to the 2021 Retiree Benefits & Enrollment Guide. . . . . . . . . . . . . . . . . . . . 4What’s New for Plan Year 2021. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Health Plans. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Contact Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Frequently Asked Questions & Answers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82021 Premium Rates. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Eligibility & EnrollmentEligibility. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Medical and Dental Plan ID Cards. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Mid-Year Enrollments and Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Qualifying Life Events Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18COBRA Continuation Coverage for Retiree Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . 22EBSD Appeals Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Medical Plan SummariesBlue Shield Signature HMO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Blue Shield Trio HMO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Blue Shield PPO. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Blue Shield PPO Medicare Coordination of Benefits (COB) Plan. . . . . . . . . . . . . . . 27Blue Shield 65 Plus (HMO). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27Kaiser Permanente HMO . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32Kaiser Permanente High Deductible Health Plan HMO. . . . . . . . . . . . . . . . . . . . . . . 33Kaiser Permanente Medicare Senior Advantage. . . . . . . . . . . . . . . . . . . . . . . . . . . . 34Important Notice About Your Medicare Prescription Drug Coverage. . . . . . . . . 36Medicare Integrated Plans – Important Information. . . . . . . . . . . . . . . . . . . . . . . . 36Non-Medicare Medical Plans Comparison Chart. . . . . . . . . . . . . . . . . . . . . . . . . . . . 38Medicare Medical Plans Comparison Chart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64Dental Plan SummariesDeltaCare USA HMO (DHMO). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74Delta Dental PPO (High and Low Options). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76Dental Plan Comparison Chart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 812link.sbcounty.gov/Retiree-Benefits
2021 San Bernardino County Retiree Benefits GuideINTRODUC TIONTABLE OF CONTENTSAdditional BenefitsRetirement Medical Trust Fund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90Health Club Membership Discounts. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92FormsWhen and How to Complete Forms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93Medical Plan Enrollment/Change Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95Dental Plan Enrollment/Change Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99Medical and/or Dental Plan Cancellation Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . 101Disabled Dependent Certification Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103Blue Shield 65 Plus (HMO) Health Plan Enrollment Form. . . . . . . . . . . . . . . . . . . 105Blue Shield Medicare Rx Plan (PDP) Enrollment Form. . . . . . . . . . . . . . . . . . . . . . 109Blue Shield 65 Plus Disenrollment Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113 Blue Shield Rx Plus (PDP) and Blue Shield Rx Enhanced (PDP)Disenrollment Form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117Kaiser Permanente Senior Advantage Election Form. . . . . . . . . . . . . . . . . . . . . . . . 121Kaiser Permanente Senior Advantage Disenrollment Form. . . . . . . . . . . . . . . . . . 127Retirement Medical Trust Fund UBA Universal Request Form. . . . . . . . . . . . . . . 129Recurring Individual Premium Reimbursement Request . . . . . . . . . . . . . . . . . . . . 131Castle Rock Trail, San Bernardino National Forest, Big Bear Lake, Californialink.sbcounty.gov/Retiree-Benefits3
2021 San Bernardino County Retiree Benefits GuideINTRODUC TIONWelcome to the 2021 Retiree Benefits & Enrollment GuideThis Guide is designed to help you understand your health benefit options during openenrollment and throughout the year. Information in this guide includes: Medical and dental plan options Monthly premiums Enrollment, change, and cancellation forms Answers to frequently asked questionsOpen Enrollment 2021Open enrollment provides you an opportunity to evaluate your current medical anddental coverage and to elect the benefit plans that best fit your needs. During openenrollment you may: Enroll in a plan Change plans Terminate coverage Add or remove dependentsElections and changes made during this open enrollment period will be effectiveJanuary 1, 2021.2021 Retiree Open Enrollment Important DatesFirst open enrollment webinar Oct. 28, 2020First day of open enrollment Nov. 1, 2020 Nov. 11, 2020EBSD office closed (Veteran’s Day) Nov. 26–27, 2020 Nov. 30, 2020 Dec. 7, 2020 Jan. 1, 2020EBSD office closed (Thanksgiving)Last day of open enrollmentLast day to submit proof of dependencyand/or dependent disabilityEffective date of new premium rates andnew elections/changesPlease contact the EBSD at 909-387-5787 or via email at ebsd@hr.sbcounty.gov shouldyou have any questions about your retiree health benefit options during open enrollmentor throughout the year.4link.sbcounty.gov/Retiree-Benefits
What’s New for Plan Year 2021?Go Green. Go Paperless.Reduce your environmental impact by signing up to receive retiree open enrollmentcommunications from EBSD electronically. Please contact EBSD at ebsd@hr.sbcounty.govto complete a Retiree Personal Information form. The Retiree Personal Information form canbe located on the EBSD Retiree Benefits page at link.sbcounty.gov/Retiree-Benefits2021 Retiree Medical and Dental Premium RatesThe County is excited to announce that the 2021 Medicare Premiums will be reduced by2.5% for the Blue Shield Medicare Advantage plans and a 6.86% reduction for the KaiserSenior Advantage plans. There are no changes to the 2021 Non-Medicare Medical andDental plans and premium rates. The 2021 Retiree Medical and Dental Premium Ratescan be located on page 11.2021 Retiree Health Plan OptionsThe following medical and dental plans are available to retirees and their eligibledependents:2021 Medical PlansNon-Medicare Plans (Choice of High & Low Options)Blue Shield of California Blue Shield Signature HMO Blue Shield Trio HMO Blue Shield PPO California Out of StateKaiser Permanente Kaiser Permanente High DeductibleHealth Plan HMO Kaiser Permanente HMO Colorado (selected zip codes) Oregon/Washington (selected zip codes)Medicare Integrated Plans (Choice of High and Low Options)Blue Shield of California Kaiser PermanenteBlue Shield 65 Plus (HMO) Kaiser Permanente Senior Advantage Colorado (selected zip codes) Oregon/Washington (selected zip codes)Medicare Coordination of Benefits PlansBlue Shield of CaliforniaBlue Shield PPO Medicare Coordination of Benefits (COB) California Out of State2021 Dental PlansDeltaCare USA DHMODelta Dental PPO (Choice of High and Low C TION2021 San Bernardino County Retiree Benefits Guide
2021 San Bernardino County Retiree Benefits GuideCONTACINTRODUCT INFORMATIONTIONCONTACT INFORMATIONEmployee Benefits andServices Division175 West Fifth Street, First Floor . . . . . 909-387-5787San Bernardino, CA 92415link.sbcounty.gov/Retiree-BenefitsAll Retiree Medical and Dental Plans . s://link.sbcounty.gov/RetireeOECOBRA . . . . . . . . . . . . . . . . . . . . . . . . . . . . 909-387-5552PROVIDERS:Blue Shield 65 Plus (HMO)www.blueshieldca.comBlue Shield 65 Plus (HMO) Member Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800-776-4466PO Box 927, Woodland Hills, CA 91365.9856Blue Shield PPO andNon.Medicarewww.blueshieldca.comBlue Shield of California . . . . . . . . . . . . 855-829-3566PO Box 272540, Chico, CA 95927.2540Blue Shield Signaturewww.blueshieldca.comPO Box 272540, Chico, CA 95927.2540. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 855-829-3566DeltaCare USA DHMOwww.deltadentalins.comPO Box 1803, Alpharetta, GA 30023. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 855-244-7323Delta Dental PPOwww.deltadentalins.comP.O. Box 9977330 Sacramento, CA 925899. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 855-244-7323Kaiser Permanentehttps://my.kp.org/sbcountyKaiser Permanente Foundation Health Plan, Inc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800-464-4000PO Box 7141, Pasadena, CA 91109.7141Kaiser PermanenteSenior Advantagehttps://my.kp.org/sbcounty6Kaiser Permanente – Medicare Unit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800-443-0815(for membership enroll/disenroll)PO Box 232400, San Diego, CA 92193.2400link.sbcounty.gov/Retiree-Benefits
CONTACT INFORMATIONVoyahttps://cosb.beready2retire.com1030 Nevada Street, Suite 203 . . . . . . 909-748-6468Redlands, CA 92374 . . . . . . . . . . . . . . . . 800-452-5842Total Administrative ServicesCorporation ( TASC )www.tasconline.comPO Box 7213, Madison, WI 53707.7213. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 866-678-8322. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1-866-450-1480 FaxHELPFUL RESOURCES AND REFERRAL SERVICES:American Association of Retired Persons (AARP) . . . . . . . . . . . . . . . . . . . . . 888-687-2277www.aarp.orgAmerican Cancer Society (ACS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800-227-2345www.cancer.orgAmerican Heart Association (AHA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800-242-8721www.heart.orgCenters for Medicare & Medicaid Services(CMS for Medicare information) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800-633-4227www.cms.govwww.medicare.govCovered California (State of California Health Care Exchange) . . . . . . . . . 800-300-1506www.coveredca.comHealth Insurance Counseling and Advocacy Program (HICAP) /California’s State Health Insurance Assistance Program . . . . . . . . . . . . . . . 800-434-0222https://www.aging.ca.gov/Programs and Services/Medicare Counseling/Social Security Administration (SSA) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 800-772-1213www.socialsecurity.govSan Bernardino County Employees’ Retirement Association (SBCERA) . . 909-885-7980348 West Hospitality Lane, Third Floor San Bernardino, CA 92415.0014 . . . e-Benefits 7CONTACINTRODUCT INFORMATIONTION2021 San Bernardino County Retiree Benefits Guide
2021 San Bernardino County Retiree Benefits GuideFrequently Asked Questions & AnswersQUESTIONS & ANSWERS1 What are the next steps when I retire? You will want to contact EBSD at 909-387-5787 for information on your healthplan options such as COBRA continuation coverage, retiree health benefit optionsand/or Medicare plan options. 2 My spouse (or domestic partner) works for the County and I am covered asa dependent under my spouse’s (or domestic partner’s) medical plan. Do Ihave to enroll in one of the retiree medical plans also?No. As a retiree, your participation in a retiree medical plan is completelyvoluntary. You may continue your coverage as a dependent under your spouse’s(or domestic partner’s) County coverage. If your spouse (or domestic partner) losesmedical coverage under a County-sponsored medical plan because of a reductionin work hours, termination of employment, or retirement, you and your spouse (ordomestic partner) might be eligible to continue group coverage through COBRA.Also, if your covered spouse (or domestic partner) retires, your spouse (ordomestic partner) will have 60 days to elect coverage as a retiree. Your spouse (ordomestic partner) may then enroll you as a covered dependent.3 How do I pay for my retiree health insurance premium/s?Yourinsurance premium/s will be deducted from your monthly retirement benefit payment (SBCERA pension check). If you do not receive a monthly retiree benefitspayment, you will need to submit payments directly to EBSD by mail or in personpayment. We accept cash, check and money order.4 What portion of the cost of my medical coverage am I responsible for?Youpay the full monthly insurance premium for medical and dental coverage. If eligible for Medicare, your advantage insurance premium is in addition to theregular MediCare Part B monthly premium.5 What should I do if the premium for my medical plan is not being deductedor is incorrect?When you enroll in a medical plan or make changes to your coverage, you shouldcheck your retirement benefit payment carefully to verify that the properdeduction is being taken. If the deduction is not being taken or is incorrect,contact EBSD immediately to correct the discrepancy.6 May I switch medical plans when I retire?At the time of retirement, you may select the retiree plan of your choice.However, if you elect COBRA continuation coverage, you may not switch plansunless you move out of your plan’s service area (see question 12). You may changeto another medical plan ONLY during open enrollment.8link.sbcounty.gov/Retiree-Benefits
7 Is there a vision plan for retirees?TheCounty of San Bernardino does not offer a retiree vision plan. View the Medical Comparison chart for additional information on covered vision exams. Ifyou are newly retired, you may continue your EyeMed vision coverage for up to 18months by electing COBRA. In addition, you may be able to obtain vision coveragewith VSP from the Retired Employees of San Bernardino County (RESBC)/PacificGroup Agencies or the Teamsters Local 1932 if you are a member. For informationabout these plans, contact Pacific Group Agencies, the Benefit Plans Administrator,at 800-511-9065 or Teamsters Local 1932 at 909-889-8377 x 234.8 When may I add new eligible dependents to my coverage?Youmay add dependents only during open enrollment unless you experience a qualifying event. You may enroll your eligible dependents (i.e., newborn newlyadopted child, new spouse, or stepchild) within 60 days of a qualifying event(birth, marriage, custody, etc.). To enroll your eligible dependents, you mustsubmit a Medical and/or Dental Plan Enrollment/Change Form (with any requiredattachments and/or verifications) within 60 days. New dependent coverage iseffective the first day of the month following the event. Exceptions: See page 17for coverage information regarding newborns and adopted children.9 What happens to my dependents’ health coverage if I become deceased?Youreligible dependents may continue to participate in the retiree medical and/ or dental plans as long as they pay the cost of the premiums.10 When does a dependent lose eligibility?Hereare some examples of events that cause a dependent to lose eligibility (see the Dependent Eligibility section of this Guide): Your non-disabled, covered child turns 26 years of age The final divorce decree is granted Dissolution of a domestic partnershipYour former spouse must be removed from your medical and dental plans within 60days of the event date even if the divorce settlement requires you to provide coverage.11 Do l have to notify anyone when a dependent becomes ineligible?Yes.You must notify EBSD within 60 days of the date your dependent becomes ineligible. If you do not notify EBSD, you will be liable for any claims paid orservices rendered on behalf of an ineligible dependent.12 If I am enrolled in an HMO plan, do I have to change medical plans if I moveoutsidethe HMO’s service area? Yes. If you move outside the service area of your plan, you will be required toenroll in another County medical plan within 60 days after the move or cancelyour coverage. Until you change or cancel your enrollment, you will only becovered under the “Out-of-Area Emergency” provision of your current HMO.link.sbcounty.gov/Retiree-Benefits9QUESTIONS & ANSWERS2021 San Bernardino County Retiree Benefits Guide
2021 San Bernardino County Retiree Benefits GuideFrequently Asked Questions & AnswersQUESTIONS & ANSWERS13 What should I do if I become (or a dependent becomes) eligible forMedicare? Three months before your 65th birthday, or when a question of eligibility comesup, you should: Call the Social Security office at 1-800-772-1213 or CMS at 1-800-633-4227regarding enrollment for Medicare insurance benefits Apply for Medicare online at https://www.ssa.gov/benefits/medicare Call EBSD at 909-387-5787 for your medical insurance options14 Can my COBRA payments be deducted from my monthly retiree benefitpayment? Yes. When you sign and date the COBRA Medical Plan Enrollment/Change Form orthe COBRA Dental Plan Enrollment/Change Form you authorize the County of SanBernardino to deduct the monthly COBRA payments from your monthly retireebenefit payment once you have paid the initial premium in full.15 Why can’t my premiums be automatically deducted from my RetirementMedicalTrust Fund, and why must I submit my receipts and forms to TASC? Since the program is a reimbursement program and not a prepayment program,expenses must be incurred before you can receive payment for them. TASC is theThird Party Administrator selected by Voya to process claim requests.16 My dependent loss coverage but I’m not currently
At the time of retirement, you may select the retiree plan of your choice. May I switch medical plans when I retire? However, if you elect COBRA continuation coverage, you may not switch plans unless you move out of your plan’s service area (see question 12). You may change to another m
